The reasonable precautions whereby the death of John Aitken might have been avoided are:

(a) That the instruction to nursing staff in Ward 14 from the Intensive Care Unit physician who was to be responsible for Mr. Aitken in the Unit that Mr. Aitken’s blood saturation levels should be continuously monitored should have been recorded in the nursing notes;

(b) That Mr. Aitken’s blood saturation levels should have been regularly monitored and recorded on his Modified Early Warning System (MEWS) chart by the nursing staff caring for him in Ward 14 before his transfer to the Intensive Care Unit;

(c) That, when it was apparent to the nursing staff in Ward 14 that no portable SATS machine to monitor Mr. Aitken’s blood saturation levels during the transfer was available in Ward 14, the Intensive Care Unit physician who had instructed continuous monitoring of these levels should have been informed;

(d) That the portable oxygen supply to Mr Aitken should have been switched on by the nursing staff responsible for the transfer after he had been disconnected from the wall mounted oxygen supply;

(e) That Mr. Aitken’s blood saturation levels should have been monitored by means of a portable SATS machine continuously throughout his transfer from Ward 14 to the Intensive Care Unit;

(f) That Mr. Aitken should have been observed (seen and looked at) continuously by the nursing staff responsible for his transfer from Ward 14 to the Intensive Care Unit.

The defects in the system of working which contributed to the death of John Aitken were:

(g) There was, in Dumfries and Galloway Royal Infirmary at the time of Mr. Aitken’s death, no formal, properly publicised and fully understood procedure for the care of ill patients during transfers between wards or departments;

(h) Observations of Mr. Aitken’s blood oxygen saturation levels and other information were not recorded on the MEWS chart prior to his transfer;

(i) Mr. Aitken did not receive ambulatory monitoring of his blood oxygen saturation levels during the transfer;

(j) Mr Aitken did not receive supplementary oxygen during the transfer;

(k) Staff on Ward 14 were not fully aware of, and lacked adequate training in, the requirements for the transfer of ill patients such as Mr Aitken from one part of the hospital to another;